Influence of the preoperative L5S1 disc state on lateral L2 to L5 fusion's outcomes at an average follow-up of 3,5 years (minimum 2 years).

INTRODUCTION: The impact of pre-existing degeneration of a disc underlying a lumbar arthrodesis via lateral approach on long-term clinical outcome has, to our knowledge, not been studied. When performing arthrodesis between L2 and L5, its extension to L5S1 is challenging because it imposes a different surgical approach. Therefore, surgeon's temptation is to not include L5S1 in the fusion even in case of discopathy. Our objective was to study the influence of the preoperative L5S1 status on the clinical outcome of lumbar lateral interbody fusion (LLIF) using a pre-psoatic approach between L2 and L5 with a minimum follow-up of 2 years. MATERIAL AND METHODS: Patients who underwent LLIF from L2 to L5 between 2015 and 2020 were included in our study. We studied VAS, ODI, and global clinical outcome before surgery and at last follow-up. The L5-S1 disc was radiologically studied in preoperative imaging. Patients were included in two groups (A "with" and B :without" L5-S1 disc degeneration) to compare the clinical outcomes at last follow-up. Our primary objective was to evaluate the rate of L5-S1 disc revision surgery at last follow-up. RESULTS: 102 patients were included. 2 required L5-S1 disc surgery following overlying arthrodesis. Our results showed a significant improvement in the patients' clinical outcomes at the last follow-up (p < 0.0001). We did not find any significant difference on clinical criteria between groups A & B. CONCLUSION: A preop L5S1 disc degeneration does not seem to impact the final clinical outcomes after lumbar lateral interbody fusion at a minimal two years F.U. It should not be systematically involved in an overlying fusion.

Incidence and impact of implant subsidence after stand-alone lateral lumbar interbody fusion.

BACKGROUND: Few data are available on the occurrence after stand-alone lateral lumbar interbody fusion (LLIF) of implant subsidence, whose definition and incidence vary across studies. The primary objective of this work was to determine the incidence of subsidence 1 year postoperatively, using an original measurement method, whose validity was first assessed. The secondary objective was to assess the clinical impact of subsidence. HYPOTHESIS: Implant subsidence after stand-alone LLIF is a common complication that can adversely affect clinical outcomes. MATERIAL AND METHODS: Of 69 included patients who underwent stand-alone LLIF, 67 (97%) were re-evaluated at least 1 year later. Furthermore, 63 (91%) patients had two available computed tomography (CT) scans for assessing subsidence, one performed immediately after surgery and the other 1 year later. Reproducibility of the original measurement method was assessed in a preliminary study. Subsidence was defined as at least 4mm loss of fused space height. RESULTS: The incidence of subsidence was 32% (20 patients). Subsidence was global in 7 (11%) patients and partial in 13 (21%) patients. Mean loss of height was 5.5±1.5mm. Subsidence predominated anteriorly in 50% of cases. The lordotic curvature of the fused segment was altered in 50% of patients, by a mean of 8°±3°. Fusion was achieved in 67/69 (97%) patients. The Oswestry score and visual analogue scale scores for low-back and nerve-root pain were significantly improved after 1 year in the overall population and in the groups with and without subsidence. DISCUSSION: Reproducibility of our measurement method was found to be excellent. Subsidence was common but without significant clinical effects after 1 year. Nevertheless, subsidence can be associated with pain and can result in loss of lumbar lordosis, which is a potential risk factor for degenerative disease of the adjacent segments. A score for predicting the risk of subsidence will now be developed by our group as a tool for improving patient selection to stand-alone LLIF. LEVEL OF EVIDENCE: IV, retrospective cohort study.

Efficacy of arthroscopic treatment for resolving infection in septic arthritis of native joints.

BACKGROUND: Septic arthritis is a diagnostic and therapeutic emergency that threatens both life and function. The primary objective of this study was to assess the efficacy on the infectious process of arthroscopic treatment in patients with septic arthritis of native joints. The secondary objective was to identify factors predicting failure to achieve infection resolution after arthroscopic treatment. We hypothesised that arthroscopy was the appropriate treatment strategy. MATERIAL AND METHODS: Forty-six cases of septic arthritis in 46 patients with a mean age of 46 years (range, 18-72 years) were retrospectively reviewed. The cause of the septic arthritis was haematogenous dissemination in 39.1% of patients, surgery in 34.8%, a local injection in 19.6%, and trauma in 6.5%. The involved joint was the knee in 32 patients, the shoulder in 6, the hip in 3, the ankle in 3, and the elbow in 2. All patients underwent arthroscopic joint lavage, with or without synovectomy depending on the Gächter stage. Dual antibiotic therapy was given routinely after the procedure. For each patient, we assessed time to treatment, intraoperative findings according to the Gächter classification, cultures of drainage-fluids, and whether repeat arthroscopic lavage was required. Recovery of the infection was defined as absence of clinical or laboratory signs of infection at last follow-up. RESULTS: Mean follow-up was 42 months (range, 1-120). Mean time from symptom onset to arthroscopic treatment was 7.5 days. Full recovery of the infection was achieved in 93% of patients, although 25% required more than one arthroscopic lavage. Factors significantly associated with arthroscopic treatment failure were Gächter stage III or IV and positive drainage-fluid cultures after 24h. CONCLUSION: Arthroscopic treatment is indicated in all patients with septic arthritis on native joints. The procedure should be repeated if the initial course is unfavourable. LEVEL OF EVIDENCE: IV. Retrospective study.

[Calcified aortic stenosis in patients over 80 years of age. Results of surgical treatment. Observations in 67 consecutive cases]. / Rétrécissement aortique calcifié chez les octogénaires. Résultats du traitement chirurgical. A propos d'une série consécutive de 67 cas.

The authors report the results of surgery performed between 1978 and 1988 for calcific aortic stenosis in 67 consecutive patients over 80 years of age; the operative risk is assessed ant the results are compared with those of balloon valvuloplasty. The operative risk seems to be relatively low (6 deaths; 8.9%). All survivors were followed-up and evaluated. The long-term results show a big improvement in survival (78.2% at 3 years) and in functional class (96% of patients in Classes I and II of the NYHA Classification). By comparison, the results of balloon valvuloplasty were very mediocre and are now generally considered to be disappointing to such an extent that the indications of dilatation seem very limited and difficult to define.

[Mitral valve replacement in postinfarction mitral insufficiency. Immediate and long-term results apropos of a series of 39 surgically-treated patients]. / Le remplacement valvulaire mitral dans l'insuffisance mitrale postinfarctus. Résultats immédiats et à long terme à propos d'une série de 39 opérés.

Thirty nine patients, mainly males (84.6%) with an average age of 66 years underwent mitral valve replacement for postinfarction mitral regurtation between March 1971 and December 1987. Twenty four were in Class IV of the NYHA Classification, 9 in Class III and 6 in Class II. All had a history of myocardial infarction predominantly of the inferior wall. The 33 preoperative coronary angiogrammes showed 13 patients with triple vessel disease, 15 with double vessel disease and 5 with single vessel disease. At operation, 13 patients had ruptured papillary muscles; acute dysfunction was observed in 16 and chronic in 10 patients. The hospital mortality was 36%; over three quarters of deaths were due to myocardial dysfunction. Twenty two patients had an associated myocardial revascularisation procedure with mitral valve replacement. All 25 survivors were followed up for an average of 2.3 years (94 patient-years). The 5 year actuarial survival (operative mortality included) was 55% and 77% of the 17 survivors are in Stages I or II of the NYHA Classification. The quality of these long-term results justifies surgery despite the high operative risk.

[20 years of mitral valve replacement. Development of a patient profile and operative mortality]. / Vingt ans de remplacements valvulaires mitraux. Evolution du profil des opérés et de la mortalité opératoire.

Between 1971 and 1991, 1,179 mitral valve replacements (MVR) were carried out in 1,134 patients. The sex ratio was stable over this period (0.7 men/women) whereas the average age of the patients increased by 10 years (50 years in 1971, 61 years in 1991). Since 1980, patients over 60 years of age represent about 60% and those over 70 years of age 16 to 22% of the population. The functional status of the patients has tended to be less severe, the NYHA stages III and IV which were initially preponderant, only represent 50 to 60% of patients operated nowadays. This reduction in the severity of symptoms is reflected in the average value of the cardio thoracic index which was 60 in 1971 and 54.8 in 1991. Similarly, the mean pulmonary artery pressures (measured in 823 patients, 69.8%) have decreased from 37.4 mmHg in 1971 to 29.9 mmHg in 1991. Rheumatic fever has tended to be replaced by degenerative etiologies which, since 1985, represent 40 to 50% of cases. Ischemic mitral regurgitation rare before 1980, is more common, presently making up 5 to 15% of MVR cases. In relation with the etiological changes mitral stenosis is giving way to mitral regurgitation as the commonest valve lesion (40 to 50% of cases in 1991). The annual operative mortality is lower (6 to 8%) than in 1982, despite the increasing number of emergency cases (7 to 10% of cases since 1985). The number of MVR with associated tricuspid valve repair has decreased with respect to isolated MVR or associated with aortocoronary bypass grafting. The only constant feature is the death rate due to myocardial dysfunction which remains over 50% whereas mortality related to the prosthetic valves varied over the years.

[Stenosis of the branches of the pulmonary artery caused by Hodgkin's lymphadenopathies]. / Sténoses des branches de l'artère pulmonaire par des adénopathies hodgkiniennes.

A 22 year old patient was admitted to hospital for dyspnoea and haemoptysis. Cardiac catheterisation showed a pressure gradient between the main pulmonary artery and its branches. Pulmonary angiography showed appearances of extrinsic compression of the branches of the pulmonary artery. This was shown to be caused by lymphadenopathy on CT scan and Hodgkin's disease was diagnosed after surgical biopsy. The pressure gradient between the main pulmonary artery and its distal branches almost completely regressed after chemotherapy and radiotherapy.

[The Carpentier-Edwards porcine valve in the supra annular aortic position. Results after 12 years in a series of 1108 patients]. / Valve porcine de Carpentier-Edwards supra annulaire en position aortique.

In the decision concerning the choice of valvular prosthesis, certain prostheses are considered to be standards of reference: this is the case of the Carpentier-Edwards Supra Annular 2650 porcine bioprosthesis. This study reports the results in a series of patients followed up for 12 years. Between 1983 and 1995, 1108 patients were implanted with this prosthesis for isolated aortic valve replacement. The majority of patients was elderly (mean 78.3 +/- 8.3 years). The follow-up rate was 94%, representing a total of 3 925 patient-years (average 4 +/- 3 years). The survival at 5, 10 and 12 years, operative mortality included, was 70.7%, 46% and 28%. Thromboembolic events to dehiscence represented the commonest complication (0.7% per patient-year). Structural valve degeneration (21 cases) (0.5% per patient-year) was a low risk complication up to 10 years but increased suddenly at the 11th year: age and gender were risk factors for this complication. The actuarial complication-free rate was 94% at 10 years and 82% at 12 years. Other complications were much less common (infectious endocarditis, haemorrage). The Carpentier-Edwards Supra Annular porcine bioprosthesis is associated with a low risk of complications after 10 years' follow-up, especially of valve degeneration. It remains a competitive choice in the register of valve prostheses. As with the other bioprostheses, the main indications are observed in elderly patients.

[Second primary cancers of the bronchi treated surgically (recurrence excluded). Results of a national survey (1987)]. / Les cancers bronchiques métachrones opérés (à l'exclusion des récidives). Résultats de l'enquête nationale (1987).

A multicentre study conducted by a number of French Thoracic Surgery centres has collected a total of 88 cases of operated metachronous cancers. After defining the concept of metachronous cancer, the reporters of this survey successively analyse the frequency, histological type and clinical course of such lesions. The various types of resection and the results (postoperative course and long-term acturial survival) are also examined in detail. The good long-term survival of such metachronous cancers justifies a deliberately "aggressive" surgical approach.

[Traumatic rupture of the aortic isthmus. Apropos of 31 surgically treated cases from 1976 to 1988]. / Ruptures traumatiques de l'isthme aortique. A propos de trente et un cas opérés de 1976 à 1988.

The authors start by presenting a series of 31 traumatic ruptures of the thoracic aorta operated at the stage of fresh rupture between January 1976 and January 1988. These lesions were caused by sudden anteroposterior (29 cases), vertical (1 case) or lateral (1 case) deceleration. The diagnosis was most frequently suggested (by enlargement of the mediastinum in 84% of cases) and was confirmed by aortography which was readily indicated. The aortic lesion was circumferential, respecting the adventitia (122 cases) or partial (8 cases). Surgical treatment consisted of restoring the aortic continuity under partial cardiopulmonary by-pass by direct suture (7 cases) or by means of a prosthesis (23 cases). The hospital mortality was 10%; the 28 survivors were reviewed with a mean follow-up of 5 years. One patient died on the 45th day after the operation due to complications of an oesophagotracheal fistula. The functional result evaluated in the 27 survivors was excellent or good in 87% of cases and poor in 13% of cases. In the light of the literature, the authors then define the principal clinical and radiological signs, discuss the various ways of medullary protection during aortic clamping, discuss the chronology of the operations to be performed (gastro-intestinal, vascular, neurosurgical and orthopaedic).

[Current operative risk in emergency coronary surgery. Experience of the last 5 years]. / Risque opératoire actuel en chirurgie coronarienne d'urgence. Expérience des cinq dernières années.

Technique of fibrinolysis and angioplasty have changed the face of emergency coronary artery surgery, which had developed considerably over recent years. Between 1982 and 1986, in the Department of Cardiovascular and Thoracic Surgery of the University Hospital of Rennes, 1,232 patients underwent isolated coronary artery revascularisation (with the exclusion of mechanical complications of infarction). 1,040 patients were operated electively and 192 patients underwent emergency surgery with very different results: mortality of 2.4% with elective surgery versus 12.5% with emergency surgery, divided into four subgroups: revascularisation after thrombolysis (gradually being replaced by angioplasty), by-pass surgery after a complication of angioplasty (or coronary angiography), by-pass surgery in threatened unresponsive infarction (now less common), by-pass surgery in the context of threatened extension of pre-existing myocardial infraction. The factors of mortality are analysed according to the circumstances (emergency, presence or absence of haemodynamic repercussions), clinical context (age, sex, previous infarction, myocardial function) and lastly the surgical possibilities (complete or incomplete revascularisation in vessels of variable quality ...). In relation to this last point, the authors stress the limitations of reasonable indications for emergency surgery, although surgery is readily proposed in deteriorating patients unresponsive to medical treatment, on vessels with a severely pathological disal bed and in myocardia with severely altered ventricular function.

[Long-term results of isolated aortic valve replacement using a Bjork-Shiley prosthesis. A clinical study of a series of 365 patients with a postoperative follow-up of 8 to 16 years]. / Résultats à long terme du remplacement valvulaire aortique isolé par la prothèse de Bjork-Shiley. Etude clinique d'une série de 365 patients comportant un recul post-opératoire de 8 à 16 années.

365 patients (mean age: 59 years) surviving isolated aortic valve replacement performed between 1971 and 1978 by means of a standard flat disk Bjork-Shiley prosthesis, underwent regular and complete follow-up (100% survival rate) representing 3,248 patient-years with a maximum follow-up of 15.4 years (mean: 8.9 years). All of these patients received anticoagulant treatment, which was considered to be well-controlled in 90.5% of cases. 121 secondary deaths (33.1%) were observed. Cardiac causes were the most frequent (35/121, i.e., 28.9%). Four deaths were directly related to the prosthesis (2 infections, 1 thrombosis, 1 dysfunction). Twenty deaths (16.5%) were related to cerebral vascular accidents and 2 (1.6%) to haemorrhagic complications. In 24 cases, the cause of death could not be determined (19.8%). Overall, 1 out of 5 deaths (21.4%) was directly or indirectly related to the prosthesis. The actuarial survival rate was 85.5% at 5 years and 67.9% at 10 years. Seventeen thromboembolic complications (7 lethal, 10 non-lethal) were observed and represented a linear incidence of 0.5% per patient-year. Fourty-one haemorrhagic complications were observed in 28 patients, i.e. a linear incidence of 1.26% per patient-year. Nine reoperations were necessary, responsible for 3 deaths. No cases of mechanical failure of the prosthesis were observed. All of the lethal and non lethal complications related to the prosthesis represented a linear incidence of 2.6% per patient-year. AT 5 and 10 years after the operation, 89.2% and 79.6% of the patients were free of any valve-related complications. The functional results was considered to be good or excellent in the very great majority of surviving patients (97.8%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgery of calcified aortic stenosis in patients aged 70 and over. Immediate results. Apropos of a series of 229 cases]. / Chirurgie du rétrécissement aortique calcifié chez les sujets âgés de 70 ans et plus. Résultats immédiats. A propos d'une série de 229 cas.

229 patients aged 70 or over with aortic stenosis (AS) underwent surgery between January 1972 and July 1983 (21.8% of 814 cases of AS operated on during the same period). The Björk Shiley prosthesis was used at the beginning of the series (115 cases, 50.2%), until bioprostheses became the treatment of choice in this age group. Overall operative mortality in the series was 10.9% (25/229). Analysis shows a very marked reduction in recent years: from 15.6% between 1972 and 1977, to 5.8% in 1982-3. Improvement can be attributed in part to the technical progress in myocardial protection. Patient age is a very significant factor in the prognosis. Progress in surgery, together with that in anaesthetics and intensive care, justifies operation in these elderly and incapacitated patients whose general and neurological condition is well preserved.

[Aortic valve replacement in persons over 75. 128 operated patients]. / Remplacement valvulaire aortique après 75 ans. 128 opérés.

Aortic valve replacements are performed in ever older subjects. In the surgical cardiovascular clinic of Rennes, 128 patients aged 75 or over (up to 85 years) and presenting with solitary or predominant (126 cases) aortic stenosis underwent aortic valve replacement between 1976 and 1985 inclusive. Pre-operative evaluation consisted, on principle, of non-invasive explorations. Myocardial protection was ensured by hypothermic cardioplegia. We used a mechanical (Björk-Shiley) prosthesis in the 19 patients operated upon before 1980, and a bioprosthesis (Carpentier-Edwards porcine, supra-annular type since 1983), in the 109 patients operated upon since 1980. The operative mortality rate was 8.6% (11 deaths). The survival curve was similar to that of a control population of the same age-group (survivors 75% at 4 years, operative mortality included). The quality of survival was remarkable since 96% of survivors were in NYHA stages I or II, the poor results being due to early or late cerebral vascular accidents. Advances in surgery (notably myocardial protection), anaesthesia and intensive care make it possible reasonably to operate upon very old patients, provided they have remained in good general and cerebral vascular condition. Non-surgical alternatives, such as percutaneous valvuloplasty, now used in elderly patients can only be reliable if results of similar quality and durability can be expected from them.

[Heart transplantation. Clinical study and results apropos of a consecutive series of 100 first grafts]. / Transplantation cardiaque. Etude clinique et résultats à propos d'une série consécutive de 100 premieres greffes.

OBJECTIVES: Global results of entire series of heart transplantations are essential to better evaluate survival rates. We therefore report the results of our first 100 transplantations. METHODS: Orthotopic heart transplantation was performed in 82 men and 18 women (age 50.5 +/- 11.4; range 9-65). Sixteen were over 60. Primitive cardiomyopathies (n = 51) and coronary artery disease (n = 44) were the most frequent underlying diseases. Secondary morbidity was evaluated according to the international classification on the basis of pathological examination of endomyocardial biopsies. RESULTS: Immediate post-operative survival rate was 89 percent: there was 1 peroperative death, 7 deaths due to persistent pulmonary hypertension and 4 due to irreversible left ventricular failure. Eight deaths occurred during the 2nd and 3rd postoperative months for an overall early survival rate of 81 percent. After a mean follow-up of 2.4 years (maximum 6.16 yr), the actuarial survival rate at 5 years was 58 percent. Among the 470 biopsies performed, rejection was classified weak or null in 326, moderate in 125 and severe in 19. Pulmonary artery resistance, immunosuppression and, later, the risk of coronary artery disease and intrinsic graft changes were the three major problems encountered in this series. CONCLUSIONS: Despite its limits, heart transplantation remains an effective therapeutic option, particularly for young patients in good general health.

[Results of surgical treatment of calcified aortic valve stenosis in 80-year-old patients]. / Rezul'tatykhirurgicheskogo lecheniia kal'tsifitsirovannogo stenoza klapana aorty u bol'nykh v vozraste 80 let.

The authors discuss surgical treatment of 67 patients for aortic stenosis in 1978-1988. Their ages ranged form 80 to 90 years. In a relatively low operative risk (8.9% mortality) the results provide evidence of marked improvement both in the functional condition (96% of patients are related to the NYHA classes I and II) and in survival (3-year survival 78.2%). The results of balloon valvuloplasty were much poorer. The indications for aortic valvuloplasty are very limited and determined with difficulty.

[A comparative evaluation of a prosthetic operation and balloon valvuloplasty in aortic valve stenosis in elderly people]. / Sravnitel'naia otsenka operatsii protezirovaniia i ballonnoi val'vuloplastiki pri stenoze klapana aorty u pozhilykh liudei.

The results of surgical treatment of aortic stenosis (AS) in elderly patients were studied in a group of 602 patients aged from 70 to 90 years (average age 74.6 years) chosen from a total number of 1,643 persons who underwent operation for AS in 1975-1988. Total operative mortality with consideration for mortality connected with combined interventions was 11.4%, in the group of isolated prosthetics it was 10.4%. The late-term results were appraised in 96.6% of patients (in 3.6 years, on the average). According to actuarial charts, survival after 3 years was 75.9%, after 5 years--66.7%, and after 7 years--55.6%. There was no difference in the survival values of recipients of biological and mechanical prostheses. Significant improvement of the functional condition was noted (96.5% of patients belonged to NYHA classes I and II). Demographic and epidemiological studies showed this pathology in the elderly to be a new problem of surgery. Surgical treatment is justified by the quality of the results, prolonged survival, and an admissible risk level even at the age of 80-90 years. Comparison with the results of aortic balloon valvuloplasty studied on basis of a rich literature review shows these to be much poorer. On the whole, only surgery may be the real method of treatment allowing effective removal of AS. The operation can be carried out even on very old patients if there are no substantiated contraindications on the part of the brain and the patient's general condition.

The hyperimmunoglobulinaemia E and recurrent infections syndrome in an adult.

A 27 year old white woman with a history of chronic eczema and episodes of serious infection of the chest, skin, and bone presented with acute respiratory failure. She was found to have a spontaneous right pneumothorax and a pneumatocele in the left upper lobe. Despite a left upper lobectomy she was left with chronic respiratory failure, bullous lung disease, and bilateral bronchiectasis. The hyperimmunoglobulinaemia E and recurrent infections syndrome was diagnosed only in adult life.